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284 Garwood Rd -. • - � SPI DAVIE COUNTY HEALTH DEPARTMENT f d u, o o IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Name Date I �j�. N2 6070 Location w ( !T1_ rr Subdivision Name Lot No. Sec. or Block No. Lot Size C`'``-``�fl House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family — Garbage Disposal YES NO,E] Specifications for System: Auto Dish Washer YES Ey NO ❑ -- - 1�1, - I\-,- - > ~ ate Auto Wash Machine YES (�Ji NO ❑ � ,,� t, Type Water Supply *This permit Void if sewage-'system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. > , 0a - 1 rl o 1 , ~ Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704- 4-59�5.�Ev, t NaCl Final Installation Diagram: System Install d by SO 13b i � ou Certificate of Completion - ��° +-� Date "The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall.in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. •F .• APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. 0. Box 665 Mockoville, ' NC 27028 ECENE� JUN 2 5 f990 .1 . Application/Permit Requested By F-((XreAf-) (.17 . LaY1PorA Mailing Address le�)l RarcS� Ln IN nC- a-k)9g Home Phone I Orp-)`t- qTN:) Business Phones Q ICA � -ag 12, 2. Name on Permit if Different than Above Te-'prc\I v Anne n L rzin K��1 3. Property Owner if Different than Above b 4. Application/Permit For: 0 General Evaluation XS/Tank Installation 5. System to Serve: House Mobile Home 0 Business Industry 0 Other 0 Unknown 6. If house, mobile home: Subdivision Sec. tLot# No. of People Dwelling Dimensions t�OC� Scv 0 No. of Bedrooms _ Basement/Plumbing No. of Bathrooms3;�-Basement/No Plumbing Washing Machine Dishwasher Garbage Disposal 7. If business, industry, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers 8. Type of water supply: Public 0 Private 0 Community 9. Property Dimensions 10. Sewage Disposal Contractor 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? 0 Yes No If yes, what type? *NOTE: . Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. � r) g0 Uate Signature Directions to Property : o 1('ra' o Cam 2c\ cnw"3 A ( in paA S�o DCHD (10-89) DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION i SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, P. O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PRQPERTY: DATE RECEIVED (office use only) G/za�ro yes no 1. 1 am the owner of the above described property. yes no 2. 1 am not the owner of the above described property, however, I certify that I have consent from ` �I�L c�� Lk 4 CL-� owner to obtain a own 's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. 1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. cl DATE 6 SIGNATURE 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: — Owner only — Owners designated representative Anyone requesting results ZOnly those listed below DATE SIGNATURE DCHD(11/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation o NAME DATE EVALUATED ADDRESS S f 'R,t' PROPERTY SIZE PROPOSED FACIILTY �N CS S LOCATION OF SITEy Water Supply: On-Site Well Community Public Evaluation By:C•kA- Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position .S _.-S'- Slope % 9-- 1-6 HORIZON I DEPTH - '� t y°' Texture groupL I-r Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC Consistence rZT Structure Ilk I< fN 19 Ir Mineralogy V. HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON — — SAPROLITE CLASSIFICATION5 LONG-TERM ACCEPTANCE RATE - 4 1 ,3 - ,5 SITE CLASSIFICATION: (�;? EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 3,S ' y OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain ' H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 RECEIVED MAY - 6 2009 NCDENR North Carolina Department of Environment and Naft ral Resources Division of Environmental Health DAVIE COUNTY HEALTH DEPARTMENT Beverly Eaves Perdue Terry L. Pierce Dee Freeman Governor Director Secretary May 4,2009 KENNETH WINDLEY 123 SOUTH MAIN STREET MOCKSVILLE,NC 27028 Re: . Final Approval Final Approval Date: 5/4/2009 GARWOOD RD WATER LINE DEH Serial#99-01191 PWSID#NCO230015 DAVIE COUNTY Dear Sir/Madam: The Department received an engineer's certification statement and an applicant's certification statement concerning the above referenced project. The engineer's certification verifies that the construction of the referenced project has been completed in accordance with the engineering plans and specifications approved under Department Serial Number 99-01191. The applicant's certification verifies that an Operation and Maintenance Plan and Emergency Management Plan have been completed and are accessible to the operator on duty at all times and available to the Department upon request and that the system will have a certified operator as required by 15A NCAC 18C .1300. The Department has determined that the requirements specified in 15A NCAC 18C .0303(a)and(c)have been met and,therefore, issues this Final Approval in accordance with Rule .0309(a). If Public Water Supply can be of further service,please call(919)733-2321. Sincerely, Tony C. Chen,P.E. Technical Services Branch Public Water Supply Section TCC:HSO cc: LEE G. SPENCER,P.E,REGIONAL ENGINEER DAVIE COUNTY HEALTH DEPARTMENT GREY ENGINEERING INC Public Water Supply Section—Jessica G.Miles,Chief One 1634 Mail Service Center,Raleigh,North Carolina 27699-1634 NorthCarohna Phone:919-733-2321\FAX:919-715-4374\Lab Form FAX:919-715-66371 Internet:ncdrinkingwater.state.naus �atu1,Q"� An Equal Opportunity\Affirmative Action Employer